Fillable Thank you for your interest in The Holman

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Thank you for your interest in The Holman

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Page 1 of 7
PRNA Updated
Date:
Thank you for your interest in The Holman Group.
Carefully complete this Reserve Network Application form in its entirety.
Please include a copy of the following: resume/CV, current licensure/ certification,
and current liability/ malpractice coverage with expiration date.
(Please complete each question, marking "N/A" if not applicable)
Name: Date of Birth:
Degree:
License (LCSW, MFCC, PSY, MD, etc:
Mailing Address:
Billing Address:
( If different from mailing address)
Street City
Primary Referral No.:
Primary Office:
State Zip Code
Monday Tuesday Wednesday Thursday Friday Saturday
Office Hours:
City State Zip Code
City
State Zip Code
Street
Street
Additional Office:
State Zip Code
Street
City
Office Telephone No.:
Fax No.:
Monday Tuesday Wednesday Thursday Friday Saturday
Office Hours:
Fax No.:
Office Telephone No.:
AL
AL
AL
AL
Page 2 of 7
PRNA Updated
License/
Certification
License/
Certification Number
Expiration
Date
Number of Years
Licensed/ Certified
List Licenses and Certifications:
How Long Have you been in practice?:
Place of Business:
Office
Home
What arrangements do you have for after-hours emergencies?:
No
Yes
Is your place of business handicap accessible?:
No
Yes
If Home office, do you have a separate entrance?:
No
Yes
If Home office, do you have a separate waiting area?:
No
Yes
Are you willing to make a home visit for exceptional client circumstances?:
No
Yes
Are you eligible to receive third party payment:
Discounted Rate: $
Carrier's Name:
Address:
Expiration Date Aggregate Maximum per Year
Please Note: The Holman Group requires at least $1 million for each occurrence, at least
1 million aggregate and such other insurance as my be required by law
Page 3 of 7
PRNA Updated
Clinical Orientation ( e.g., cognitive behavioral):
Ages: Child Adolescent:
Geriatric:
Adult:
Group:
Family:Couples:Modalities: Individual
Indicate all specialty areas of treatment you provide by estimating the number of clients you have seen
since you have been in practice:
Other DepressionADD Major DepressionADHD
Anxiety/Panic DisrorderHIV/AIDS StressCD
Domestic ViolencePTSD Anger ManagementParenting
Sex Abuse PerpetratorsChild Abuse Sex Abuse Victims
Autism/PDD
Conduct Disorder under age 10 Conduct Disorder over age 10
Severe Emotional Disturbance of Children 12 or under Anorexia Nervosa
Grief/LossWomen's IssuesSchizophreniaBulimnia
Hypnosis Gay/Lesbian Issues Neuropsychology Work Problem
NLP EMDR Christian Counseling Meditation Instruction
Substance Abuse Specialist (SAP) Homeless Populations in Prison
Workers' Compensation Disability
Other Specialties ( Please List):
Are you Available to do Emergency on-Site Counseling for Employer Groups?:
No
Yes
Specific Cultural and Occupational Expertise ( Please Estimate the Number of Clients Seen
African American Asian/Pacific Islander Hispanic/Latino
Mixed Racial Issues Native American Police Fire/Paramedic/EMT
Page 4 of 7
PRNA Updated
Referrals/Populations with whom you would prefer not to work:
ViolentPsychoticBorderlineSex Abuse Perpetrators CD
Children/Adolescents under
Others:
How do community based resources and support groups (e.g., 12-Step) play a role in your treatment
philosophy?:
Optional: Please provide any additional information which will be helpful in fulfilling specific request
(e.g., gender, ethnicity, cultural orientation, relligion, religious preference):
Other languages spoken:
Please list any therapy groups that you currently lead or have previously lead
Current
Current
Current
Current
CurrentCurrent
Are you Available to do Emergency on-Site Counseling for Employer Groups?:
No
Yes
Would you be willing to participate in a training for pre-surgery preparation
programs if The Holman Group Provided such training?:
No
Yes
Have you had experience working in the specialty area of health psychology?:
No
Yes
Have you had experiences working in collaboration with the medical profession, i.e., primary care physicians,
involving any of the following medical conditions?:
Arthritis & Rheumatic Diseases . . . .
No
Yes
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . .
No
Yes
Ischemic Heart Diseases . . . . . . . . . .
No
Yes
Diabetes . . . . . . . . . . . . . . . . . . . . . . . .
No
Yes
Hypertension . . . . . . . . . . . . . . . . . . . .
No
Yes
Emphysema. . . . . . . . . . . . . . . . . . . . . .
No
Yes
Page 5 of 7
PRNA Updated
Primary Hospital: From:
From:Hospital:
City:Street:
State
Zip Code:
City:Street:
State
Zip Code:
From time to time, Holman is looking for licensed therapist that have experience in presenting trainings,
educational programs and/or doing Critical Incident Stress Debriefings (CISD) (Mitchell Model). We would
appreciate knowing your experience in any of these areas. If you know of other licensed therapists with
this experience that you would recommend, please do so:
1.
2.
3.
4.
5.
Topic of Training/Education
Number of Hours of Experience
Referral Name:
Address:
Zip CodeStateCityStreet
Office Telephone No.:
E-mail Address
AL
AL
AL
Page 6 of 7
PRNA Updated
Primary Hospital:
City:Street:
State
Zip Code:
From:
Primary Hospital:
City:Street:
State
Zip Code:
From:
Hospital:
City:Street:
State
Zip Code:
From:
Check the box(es) below with your current professional affiliation(s)
American Association of Marriage & Family Therapists
American Board of Examiners in Clinical Social work
American Board of Medical Specialties
American Psychological Association
National Association of Social Workers
National Register of Health Service Providers in Psychology
Other, Please Specify:
AL
AL
AL
Print Your Form
Page 7 of 7
PRNA Updated
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Thank you for your interest in The Holman

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Completed 23 January 2021

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